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Registered Nurse - Medical Unit - Day Shift (Sign on bonus!)

Company: University of New Mexico - Hospitals
Location: Edgewood
Posted on: June 7, 2024

Job Description:

Sign-on Bonus and Relocation Reimbursement available!
Receive 17% weekday nights, 26% weekend nights, or 15% weekend day shift differentials!

Full Time
Shift: Days

Responsible for concurrent review of appropriate and complete clinical documentation in the electronic medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improved medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for caregivers in appropriate clinical documentation as indicated. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG. CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate
* COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate "query" tools in order to capture the documentation in the medical record that accurately supports the patient's severity of illness
* PROBLEM-SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity, risk of mortality, length of stay. ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested. PHYSICIAN COMMUNICATION - Participate in clinical rounding and other communication with physicians and residents on the inpatient units to obtain/clarify specific principal diagnoses or comorbidities and complications that pertain to the clinical information shared on specific patients during rounding; facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines
* COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. PROCESS IMPROVEMENT - Analyze baseline outcomes; develop process improvement plans to improve baseline to a higher level of performance; prioritize and implement process improvement action plans; REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software. EDUCATION - Use query statistics and query type information to create training materials for physicians and ancillary staff. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. LEADERSHIP - Demonstrate strong clinical documentation leadership skills to become a valuable CDI specialist for medical departments and divisions assigned
* Certified Document Improvement Practitioner
Certified Coding Specialist
Minor Hazard - physical risks, dirt, dust, fumes, noise

Keywords: University of New Mexico - Hospitals, Albuquerque , Registered Nurse - Medical Unit - Day Shift (Sign on bonus!), Healthcare , Edgewood, New Mexico

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